Canadian Fundamentals of Nursing - 5 th ed.

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1 Canadian Fundamentals of Nursing - 5 th ed. 11 Critical Thinking in Nursing Practice Original chapter by Patricia A. Potter, RN, MSN, PhD, FAAN Canadian content written by Donna M. Romyn, RN, PhD objectives Mastery of content in this chapter will enable you to: Define the key terms listed. Describe characteristics of a critical thinker. Describe the components of a critical thinking model for clinical decision making. Explain the relationship between clinical experience and critical thinking. Discuss critical thinking competencies used in nursing practice. Discuss the nurse's responsibility in making clinical decisions. Discuss the relationship of the nursing process to critical thinking. Discuss the critical thinking qualities used in clinical decision making. Explain how professional standards influence a nurse's clinical decisions. Describe how reflective journal writing promotes critical thinking. Discuss how concept maps can improve a nurse's ability to think critically. Key terms: Clinical decision-making process, p. 141 Clinical inference, p. 145 Chapter 11. Critical Thinking in Nursing Page 1 of 28

2 Concept map, p. 149 Critical thinking, p. 141 Decision making, p. 145 Diagnostic reasoning, p. 145 Evidence-informed knowledge, p. 141 Nursing process, p. 142 Problem solving, p. 145 Reflection, p. 148 Reflective journal writing, p. 148 Scientific method, p. 144 As a nurse, you will face many complex situations involving patients, family members, and other health care workers. To deal with these experiences effectively, you need to develop sound critical thinking skills so that you can approach each new problem involving a patient's care with open-mindedness, creativity, confidence, and wisdom. When a patient develops a new set of symptoms, asks you to provide comfort, or requires a procedure, it is important to think critically and make prudent clinical judgements so that the patient receives the best nursing care possible. Critical thinking is not a simple, step-by-step linear process that you can learn overnight. Your ability to think critically will increase as you gain experience and progress from novice to expert nurse (Benner, 1984). Critical thinking is central to professional nursing practice because it allows you to test and refine nursing approaches, learn from successes and failures, apply new knowledge (e.g., nursing research findings), and ensure holistic patient-centred care. Critical Thinking Defined Critical thinking is a complex phenomenon that can be defined as a process and as a set of skills. Most definitions of critical thinking emphasize the use of logic and reasoning (Di Vito-Thomas, 2005) to make accurate clinical judgements and decisions. Accordingly, nurses recognize that an issue (e.g., patient problem or health-related concern) exists, analyze information about the issue (e.g., clinical data about the patient), evaluate information (e.g., review assumptions and evidence), and draw conclusions (Settersten & Lauver, 2004). In consultation with patients, nurses consider what is important in a situation, imagine and explore alternative solutions, consider ethical principles, and then make informed decisions about how to proceed. Consider the following case example: Mr. Jacobs is a 58-year-old patient who had a radical prostatectomy for prostate cancer yesterday. His nurse, Tonya, finds him lying supine in bed with his arms extended along his sides and his hands clenched. When Tonya checks his surgical wound and drainage device, she notes that he winces when she gently palpates over the incisional area. She asks Mr. Chapter 11. Critical Thinking in Nursing Page 2 of 28

3 Jacobs when he last turned onto his side, and he responds, Not since sometime last night. Tonya asks Mr. Jacobs if he is having incisional pain and he nods, saying, It hurts too much to move. Tonya considers her observations and the information she has learned from the patient to determine that his pain is severe and his mobility is reduced because of it. Together, she and Mr. Jacobs decide to take action to relieve Mr. Jacob's pain so he can turn more frequently and begin to get out of bed to aid his recovery. Critical thinking requires purposeful and reflective reasoning during which you examine ideas, assumptions and beliefs, principles, conclusions, and actions within the context of the situation (Brunt 2005a, 2005b). When you care for a patient, you begin to think critically by asking questions such as What do I know about the patient's situation? How do I know it? What is the patient's situation now? How might it change? What else do I need to know to understand this situation better or improve it? How can I obtain that information? In what way will a specific therapy affect the patient? Are other options available? By answering these questions, you are able to identify alternative solutions to resolve the patient's health-related concerns. As you gain experience in nursing, avoid letting your thinking become routine or standardized. Instead, learn to look beyond the obvious in any clinical situation, explore the patient's unique responses to actual or potential health alterations, and recognize what actions are needed to benefit the patient. Over time, your experience with many patients will help you recognize patterns of behaviour (Tanner, 2006), see commonalities in signs and symptoms, and anticipate reactions to nursing interventions. Reflecting on your experiences will allow you to better anticipate patients' needs and recognize problems when they develop. It will also help you determine how the knowledge you gained working with one patient may be applicable to another patient's situation. In Tonya's case, she knows that the patient is likely to have pain because the surgery was extensive. Her review of her observations and the patient's report of pain confirm that pain is a problem. Her options include giving Mr. Jacobs an analgesic and then waiting until it takes effect so that she can help him find a more comfortable position. Once his pain is less acute, Tonya might also ask Mr. Jacobs whether he would like to try some relaxation exercises and mobilization techniques she learned while caring for another postoperative patient that may be effective in increasing his mobility. You can begin to learn to think critically early in your practice. For example, as you learn about administering bed baths and other hygiene measures to your patients, take time to read this book and the nursing literature about the concept of comfort. What are the criteria for comfort? How do patients from other cultures perceive comfort? What are the many factors that promote comfort? Learning and thinking critically about the concept of comfort, in addition to acquiring the skills needed to provide comfort measures, prepares you to better Chapter 11. Critical Thinking in Nursing Page 3 of 28

4 anticipate your patients' needs. You will also identify comfort problems more quickly and offer appropriate care. The use of evidence-informed knowledge knowledge based on research or clinical expertise makes you an informed critical thinker. Critical thinking requires not only cognitive skills, such as interpretation, analysis, inference, evaluation, explanation, and self-regulation, but also a nurse's habit (disposition) to ask questions, to be well informed, to be honest in facing personal biases, and to always be willing to reconsider and think differently about issues. Without these dispositions, sound critical thinking is unlikely to occur (Facione, 1990; Facione & Facione, 1996; Profetto- McGrath, 2003). When applied to nursing, these core critical thinking skills and critical thinking dispositions reveal the complex nature of the clinical decision-making process (Table 11-1). Being able to apply all of these skills and acquiring all of these critical thinking habits take time and practice. You also need to have a sound knowledge base and thoughtfully consider the knowledge you gain when caring for patients. Being open-minded, inquisitive, and systematic in thinking about practice situations will also help you incorporate research findings in your clinical decision making (Profetto-McGrath et al., 2003). Nurses who apply critical thinking in their work consider all aspects of a situation and make well-reasoned judgements about a variety of possible alternative actions rather than hastily and carelessly implementing solutions (Kataoka-Yahiro & Saylor, 1994). For example, nurses who work in crisis situations such as child abuse and suicide prevention programs act quickly when patient problems develop. These nurses must, however, exercise discipline in decision making to avoid premature and inappropriate decisions. Learning to think critically helps you to care for patients as their advocate and to make better informed choices about their care. Critical thinking is more than just problem solving; it is an attempt to continually improve how you apply knowledge when faced with problems in patient care. A Critical Thinking Model for Clinical Decision Making Thinking critically is becoming the benchmark or standard for professional nursing competence. To help you in the development of critical thinking, this text offers a model for critical thinking. Because critical thinking in nursing is complex, a model helps explain what is involved as you make clinical decisions and judgements about your patients. Kataoka- Yahiro and Saylor (1994) developed a model of critical thinking for nursing judgement based in part on previous work by Paul (1993), Glaser (1941), Perry (1979), and Miller and Malcolm (1990) (Figure 11-1). The model defines the outcome of critical thinking: nursing judgement that is relevant to nursing problems in a variety of settings. TABLE 11-1 Critical Thinking Skills and Dispositions Chapter 11. Critical Thinking in Nursing Page 4 of 28

5 Elements of Decision-Making Process Critical Thinking Behaviour Skill Interpretation Be orderly in data collection. Look for patterns to categorize data (e.g., formulate nursing diagnoses [see Chapter 12]). Clarify any data about which you are uncertain. Analysis Be open-minded as you look at information about a patient. Do not make careless assumptions. Ask whether the data reveal what you believe is true or whether other scenarios are possible. Inference Examine meanings and relationships in the data. Form reasonable hypotheses and conclusions, on the basis of the patterns observed. Explanation Assess all situations objectively. Use criteria (e.g., expected outcomes) to determine the effectiveness of nursing actions. Identify required changes. Reflect on your own behaviour. Explanation Support your findings and conclusions. Use knowledge and experience to select the strategies you use in the care of patients. Self-regulation Reflect on your experiences. Adhere to standards of practice. Apply ethical principles in your nursing practice. Identify in what way you can improve your own performance. Dispositions or Habits Truth seeking Chapter 11. Critical Thinking in Nursing Page 5 of 28

6 Learn what is actually happening in a situation. Consider scientific principles and evidence, even if they do not support your preconceptions or personal beliefs. Open-mindedness Be receptive to new ideas and tolerant of other points of view. Respect the right of other people to hold different opinions. Be aware of your own prejudices. Analyticity Determine the significance of a situation. Interpret meaning. Anticipate possible results or consequences. Use evidence-informed knowledge in your nursing practice. Systematicity Be organized and focused in data collection. Use an organized approach to problem solving and decision making. Self-confidence Trust your own reasoning processes. Seek confirmation from experts when uncertain. Inquisitiveness Actively seek new knowledge. Maturity Accept that multiple solutions are possible. Reflect on your own judgements; be willing to consider other explanations. Use prudence in making, suspending, or revising judgements. Adapted from Facione, P. (1990). Critical thinking: A statement of expert consensus for purposes of educational assessment and instruction. The Delphi report: Research findings and recommendations prepared for the American Philosophical Association (ERIC Doc No. ED ). Washington, DC: Educational Resources Information Center (ERIC). Throughout this text, this model is used for applying critical thinking during the nursing process (see Chapter 5). Each clinical chapter of the text (Chapters 31 to 48) is organized by the steps of the nursing process and includes both scientific and nursing knowledge. It is your Chapter 11. Critical Thinking in Nursing Page 6 of 28

7 knowledge base (the first critical thinking component) that prepares you to make clinical judgements as a nurse. Figure 11-1 demonstrates how to apply elements of critical thinking in assessing patients, in planning the interventions you provide, and in evaluating your results. Applying each element of this model in the way you think about patients will help you become a confident and effective professional. Levels of Critical Thinking in Nursing Your ability to think critically grows as you gain new knowledge and experience in nursing practice. Kataoka-Yahiro and Saylor (1994) developed a critical thinking model that incorporates three levels of critical thinking in nursing: basic, complex, and commitment. As a beginning nursing student, you apply the critical thinking model at the basic level. As you advance in practice, you adopt complex critical thinking and commitment. Basic Critical Thinking At the basic level of critical thinking, a learner trusts that experts have the right answers for every problem. Thinking is concrete and based on a set of rules or principles. For example, as a student nurse, you use a hospital's procedure manual to confirm how to insert a Foley catheter. In completing this procedure for the first time, you will probably follow the procedure step by step without adjusting the procedure to meet a patient's unique needs (e.g., positioning to minimize the patient's pain or mobility restrictions) because you do not have enough experience to know how to individualize the procedure. At this level, answers to complex problems are seen to be either right or wrong (e.g., the Foley catheter balloon contains too much or not enough sterile water), and you may believe that one right answer exists for each problem. As you gain more experience in nursing, you will begin to explore the diverse opinions and values of experts (e.g., instructors and staff nurse role models) and engage in more complex critical thinking. Complex Critical Thinking When you engage in complex critical thinking, you begin to separate your thinking processes from those of authorities and to analyze and examine choices more independently. Your thinking abilities and initiative to look beyond expert opinion begin to change, as you realize that alternative, and perhaps conflicting, solutions to a problem or issue exist. Consider the following case study: Chapter 11. Critical Thinking in Nursing Page 7 of 28

8 Mr. Rosen is a 36-year-old man who injured his back in a skiing accident. He suffers from chronic pain but is refusing to take a prescribed analgesic. While discussing the importance of rehabilitation with Mr. Rosen, the nurse, Edwina, learns that Mr. Rosen practises meditation at home. In complex critical thinking, Edwina recognizes that for pain relief, the patient has options other than accepting analgesics. Edwina decides to also discuss other nonpharmacological interventions with Mr. Rosen and his other health care providers even though not all may agree about their potential efficacy in controlling his pain. In complex critical thinking, you are willing to consider other options in addition to routine procedures when complex situations develop. As a nurse, you learn to weigh the benefits and risks of each potential solution before making a final decision. Thinking becomes more creative and innovative as you explore a broad range of perspectives and alternative solutions. Commitment The third level of critical thinking is commitment. You anticipate the need to make choices without assistance from Figure 11-1 Critical thinking model for nursing judgement. Chapter 11. Critical Thinking in Nursing Page 8 of 28

9 Source: Redrawn from Kataoka-Yahiro, M., & Saylor, C. (1994). A critical thinking model for nursing judgment. Journal of Nursing Education, 33(8), 351. Adapted from Glaser, E. (1941). An experiment in the development of critical thinking. New York: Bureau of Publications, Teachers College, Columbia University; Miller, M., & Malcolm, N. (1990). Critical thinking in the nursing curriculum. Nursing & Health Care, 11, 67; Paul, R. W. (1993). The art of redesigning instruction. In Willsen, J., Blinker, A. J. A. (Eds.). Critical thinking: How to prepare students for a rapidly changing world. Santa Rosa, CA: Foundation for Critical Thinking; and Perry, W. Chapter 11. Critical Thinking in Nursing Page 9 of 28

10 (1979). Forms of intellectual and ethical development in the college years: A scheme. New York: Holt, Rinehart, & Winston. other professionals, and then you assume responsibility and accountability for those choices. As a nurse, you do more than just consider the complex alternative solutions that a problem poses. At the commitment level, you choose an action or belief on the basis of the alternative solutions available, and you stand by your choice. Sometimes an action is to not take action, or you may choose to delay an action until a later time as a result of your experience and knowledge. Because you take accountability for the decision, you give attention to the results of the decision and determine whether it was appropriate. Components of Critical Thinking in Nursing Critical thinking consists of five components: knowledge base, experience, competencies, qualities, and standards. These elements explain how nurses make clinical judgements that are necessary for safe, effective nursing care (Box 11-1). Specific Knowledge Base To think critically, establish accurate clinical judgements and decisions, and improve clinical practice (Di Vito-Thomas, 2005), nurses must possess a sound knowledge base. Your knowledge base includes information and theory from the basic sciences, humanities, behavioural sciences, and nursing. Nurses use their knowledge base in a different way than other health care providers because they think holistically about patient problems and health-related matters. For example, a nurse's broad knowledge base offers a physical, psychological, social, moral, ethical, and cultural view of patients and their health concerns. The breadth and depth of your knowledge influences your ability to think critically about nursing problems. Consider the scenario on the following page: Box 11-1 Components of Critical Thinking in Nursing I. Specific knowledge base II. Experience in nursing III. Critical thinking competencies A. General critical thinking competencies (scientific method, problem solving, and decision making) B. Specific critical thinking competencies in clinical situations (diagnostic reasoning, clinical inference, and clinical decision making) Chapter 11. Critical Thinking in Nursing Page 10 of 28

11 C. Specific critical thinking competency in nursing (use of nursing process) IV. Attitudes for critical thinking V. Standards for critical thinking A. Intellectual standards B. Professional standards 1. Ethical criteria for nursing judgement 2. Criteria for evaluation 3. Professional responsibility Adapted from Kataoka-Yahiro, M., & Saylor, C. (1994). A critical thinking model for nursing judgment. Journal of Nursing Education, 33(8), 351. Data from Paul, R. W. (1993). The art of redesigning instruction. In Willsen, J., & Blinker, A. J. A. (Eds.). Critical thinking: How to prepare students for a rapidly changing world. Santa Rosa, CA: Foundation for Critical Thinking. Robert Perez previously earned a bachelor's degree in education and taught high school for one year. He has successfully completed the required human and biological science courses in his nursing program as well as those related to health ethics, fundamental nursing concepts, and communication principles. His first clinical course focuses on health promotion, with a clinical assignment in an outpatient primary care clinic. Although he is still new to nursing, his experience as a teacher and his preparation and knowledge base in nursing will help him know how to begin to make clinical decisions about patients' self-care and health promotion practices. Experience Nursing is a practice discipline. Clinical nursing experiences are necessary for you to acquire clinical decision-making skills (Roche, 2002). In clinical situations, you learn from observing, sensing, talking with patients and families, and then reflecting actively on your experiences. Clinical experience is the laboratory for evaluating nursing knowledge. You learn that textbook approaches form the basis for nursing practice, but you make safe adaptations or revisions in approaches to accommodate the setting, the unique qualities of the patient, and the experience you gained from caring for previous patients. With experience, you begin to understand clinical situations, recognize cues of patients' health patterns, and interpret cues as relevant or irrelevant (Tanner, 2006), and your critical Chapter 11. Critical Thinking in Nursing Page 11 of 28

12 thinking skills advance beyond the basic level. You also learn to seek new knowledge as needed, act quickly when events change, and make quality decisions that promote the patient's well-being. It is important for you to admit to any limitations in your knowledge and skills. Critical thinkers admit what they do not know and try to acquire the knowledge needed to make correct decisions. A patient's safety and welfare are at risk if you do not admit your inability to deal with a practice problem. You must rethink the situation, acquire additional knowledge, and then use new information to form opinions, draw conclusions, and take appropriate action. Perhaps the best lesson to be learned by a new nursing student is to value all patient experiences, which enable you to build new knowledge and inspire innovative thinking. During the previous summer, Robert worked as a nurse assistant in a long-term care facility. This experience provided him with valuable experience in interacting with older adults and in giving basic nursing care. Specifically, he has been able to develop good interviewing skills and understand the importance of the family in an individual's health. He has also learned that older adults require more time to perform activities such as eating, bathing, and grooming, and so he has adapted skill techniques for dealing with this requirement. His time in the physical assessment laboratory and the time he worked in the nursing home helped him begin to be a careful observer. As he reflects on his experiences, Robert also knows that much of what he learned can be applied in promoting health, wellness, and independence among the older patients who attend the outpatient primary care clinic for routine follow-up visits. Becoming familiar with practice standards developed by clinical experts assists you in enhancing your knowledge base. For example, the Best Practice Guidelines developed by the Registered Nurses' Association of Ontario (RNAO) include standards for patientcentred nursing care and for a number of clinical conditions, such as asthma, chronic obstructive pulmonary disease, diabetes, and depression. Other standards focus on nursing practice issues such as embracing cultural diversity and fostering collaborative practice. Visit the RNAO's Web site ( as well as the Web site of the professional nursing association in the province or territory in which you reside, to learn more about the wide range of practice guidelines and to develop a sound knowledge base for your nursing practice. Including a focus on wellness in the care you provide means you also need to think about how the social determinants of health (see Chapter 1) influence patient access to the resources they need in the community to deal with chronic disease, prevent illness and injury, and increase their health and well-being (Canadian Nurses Association, 2009). Incorporating interprofessional collaboration, including shared decision making and working in partnership with other health providers, in your practice as a nurse enhances health outcomes for the individuals, families, and communities you encounter (Canadian Interprofessional Health Collaborative, 2010). Chapter 11. Critical Thinking in Nursing Page 12 of 28

13 Critical Thinking Competencies Kataoka-Yahiro and Saylor (1994) described critical thinking competencies as the cognitive processes that a nurse uses to make judgements about the clinical care of patients. They include general critical thinking, specific critical thinking in clinical situations, and specific critical thinking in nursing. General critical thinking competencies are not unique to nursing. They include the scientific method, problem solving, and decision making. Specific critical thinking competencies in clinical situations include diagnostic reasoning, clinical inference, and clinical decision making. The specific critical thinking competency in nursing involves use of the nursing process. General Critical Thinking Competencies Scientific Method. The scientific method is a systematic, ordered approach to gathering data and solving problems that is used in nursing, medicine, and various other disciplines. Nurse researchers use the scientific method to verify that a set of facts is true when testing research questions in nursing practice situations. Research incorporating the scientific method contributes to evidence-informed nursing practice and the development of best practice guidelines. The scientific method has five steps: Identification of the problem Collection of data Formulation of a research question or hypothesis Testing of the question or hypothesis Evaluation of the results of the test or study Consider the following example of the scientific method in nursing practice: A nurse caring for patients who receive large doses of chemotherapy for ovarian cancer detects a pattern whereby these patients develop severe inflammation of the mouth (mucositis) (identifies the problem). The nurse reads research articles (collects data) about mucositis and learns about evidence that cryotherapy, in which patients keep ice in their mouths during the chemotherapy infusion, reduces the severity of the Chapter 11. Critical Thinking in Nursing Page 13 of 28

14 mucositis after treatment. The nurse asks (forms research question), Can ovarian cancer patients who receive chemotherapy have less severe mucositis when given cryotherapy instead of standard mouth rinse in the oral cavity? The nurse then designs a study that compares the incidence and severity of mucositis in a group of patients who use cryotherapy with those in patients who use traditional mouth rinse (tests the question). The nurse hopes that the results from the study will give oncology nurses a better approach for reducing the frequency and severity of mucositis in cancer patients. A nurse in another oncology setting critically analyzes the study before implementing its recommendations for patient care (evaluates the results of the study). Problem Solving. Everyone faces problems every day. When a problem arises, people obtain information and then use the information, in addition to what they already know, to find a solution. patients routinely present problems in nursing practice. For example, a home care nurse visits a patient and learns that the patient cannot describe what medications she has taken for the past three days. The nurse must solve the problem of why the patient is not adhering to her medication schedule. The nurse knows the patient was recently discharged from the hospital and five medications were prescribed. When the nurse asks the patient to show the medications that she takes in the morning, the nurse notices that the patient has difficulty reading the medication labels. The patient is able to tell the nurse the names of the medications she is to take but is uncertain about the times of administration. The nurse recommends having the patient's pharmacy relabel the medications in larger lettering. In addition, the nurse shows the patient examples of pill organizers that will help her sort her medications by time of day for a period of seven days. Effective problem solving also involves evaluating the solution over time to be sure that it is still effective. It becomes necessary to try different options if a problem recurs. As a continuation of the example just described, the nurse finds during a follow-up visit that the patient has organized her medications correctly and is able to read the labels without difficulty. The nurse obtained information that correctly clarified the cause of the patient's problem, and the nurse tested a solution that proved successful. Having solved a problem in one situation adds to the nurse's experience in practice and allows the nurse to apply that knowledge in future situations with patients. Decision Making. When you face a problem or situation and need to choose a course of action from several options, you are making a decision. Decision making is a product of critical thinking that Chapter 11. Critical Thinking in Nursing Page 14 of 28

15 focuses on problem resolution. Following a set of criteria helps you make a well-reasoned decision. For example, decision making occurs when a person chooses a fitness consultant. To make a decision, the person has to recognize and define the problem (need for a physical activity) and assess all options (consider recommended trainers or choose one on the basis of proximity to the person's home). The person has to weigh each option against a set of criteria (e.g., credentials, reputation, experience), test possible options (interview potential trainers, assess safety of equipment), consider the consequences of the decision (increased fitness, risk of injury), and then make a final decision. Although the criteria follow a sequence of steps, decision making involves moving back and forth between steps when all criteria are considered. Decision making leads to informed conclusions that are supported by evidence and reason. Examples of decision making include deciding on a choice of dressings for a patient with a surgical wound or selecting the best approach for teaching a family how to assist a patient who is returning home after a stroke. You learn to make sound decisions by approaching each clinical situation thoughtfully and by applying each component of the decision-making process described previously. Specific Critical Thinking Competencies in Clinical Situations Diagnostic Reasoning and Inference. As soon as you receive information about a patient in a clinical situation, you begin diagnostic reasoning, a process of determining a patient's health status after you make physical and behavioural observations and after you assign meaning to the behaviours, physical signs, and symptoms exhibited by the patient. The information that you collect and analyze leads to a diagnosis of the patient's condition. An expert nurse sees the context of a patient situation (e.g., recognizes that a patient who is feeling lightheaded, has blurred vision, and has a history of diabetes is experiencing a problem with blood glucose levels), observes patterns and themes (e.g., symptoms including weakness, headache, hunger, and visual disturbances that suggest hypoglycemia), and chooses an appropriate intervention quickly (e.g., offers a food source containing glucose) (Ferrario, 2004). Considering the context of the situation enhances the nurse's analytic skills (Ironside, 2005) and results in a more accurate diagnosis. Part of diagnostic reasoning is clinical inference: the process of drawing conclusions from related pieces of evidence (Smith Higuchi & Donald, 2002). An inference involves forming patterns of information from data before making a diagnosis. Seeing that a patient has lost his appetite and experienced a loss of weight over the past month, the nurse infers that the patient has a nutritional problem. An example of diagnostic Chapter 11. Critical Thinking in Nursing Page 15 of 28

16 reasoning is forming a nursing diagnosis such as imbalanced nutrition, less than body requirements (see Chapter 42). Often you cannot make a precise nursing diagnosis during your first meeting with a patient. You will sometimes sense that a problem or health concern exists, but you do not have sufficient data to make a specific diagnosis. Some patients' physical conditions limit their ability to tell you about symptoms. Other patients may choose not to share sensitive and important information during your initial assessment. Patients' behaviours and physical responses may become observable only under certain conditions not present during your initial assessment. When you are uncertain of a diagnosis, continue data collection, which may include consulting with expert nurses or other health care providers. As a nurse, you must critically analyze changing clinical situations until you are able to determine the patient's unique situation. Diagnostic reasoning is a continuous behaviour in nursing practice. In diagnostic reasoning, use patient data that you gather to logically explain a clinical judgement. For example, after turning a patient over in bed, you see an area of redness and a small blister on his right hip. You palpate the area and note that it is warm to the touch, and the patient complains of tenderness there. You push on the area with your finger, and, after you release pressure, the area does not blanch or turn white. You think about what you know about normal skin integrity and the effects of pressure. You form the conclusion the patient has a Stage I pressure ulcer. As a new student, confirm your judgement with experienced nurses. At times, your clinical judgement may be incorrect (e.g., a blistered area is indicative of a Stage II pressure ulcer; however, nurse experts will give you feedback to build on in future clinical situations. Nurses do not make medical diagnoses, but they do assess and monitor patients closely and compare the patient's signs and symptoms with those that are common to a medical diagnosis. This type of diagnostic reasoning helps nurses and other health care providers pinpoint the nature of a problem more quickly and select proper interventions. Similarities and differences between medical and nursing diagnoses are described in more detail in Chapter 12. Clinical Decision Making. Clinical decision making is a problem-solving activity that focuses on defining patient problems and selecting appropriate treatments (Smith Higuchi & Donald, 2002). Nurses are responsible for making accurate and appropriate clinical decisions. Clinical decision making distinguishes professional nurses from technical personnel. It is the professional Chapter 11. Critical Thinking in Nursing Page 16 of 28

17 nurse, for example, who takes immediate action when a patient's clinical condition deteriorates, decides whether a patient is experiencing complications that call for notification of a physician, or decides whether a teaching plan for a patient is ineffective and necessitates revision. Benner (1984) described clinical decision making as judgement that includes critical and reflective thinking and action and the application of scientific and practical knowledge. Clinical judgement requires that you recognize the salient aspects of a clinical situation, interpret their meanings, and respond appropriately. It includes four components: noticing or grasping the situation; interpreting or developing a sufficient understanding of the situation to respond; responding or deciding on a course of action; and reflecting on or reviewing the actions taken and their outcomes. In making a clinical judgement, you consider the context of the situation and rely on analytic processes, intuition, and narrative thinking (i.e., thinking that occurs as a result of telling and interpreting stories). As you reflect on actions taken, you acquire clinical learning, which contributes to future clinical judgements (Tanner, 2006). Nurses regularly encounter practice situations in which little is straightforward (Hartrick Doane & Brown, 2011). Each patient's problems are unique and products of many factors, including the patient's physical health, lifestyle, culture, relationship with family and friends, living environment, and experiences. As a nurse, you do not always have a clear picture of the patient's needs and the appropriate actions to take when you first meet a patient. Instead, you must learn to question and explore different perspectives and interpretations in order to find a solution that benefits the patient (Box 11-2). When you approach a clinical problem, such as a patient who is experiencing difficulty walking, you make a decision that identifies the problem (e.g., right-sided weakness) and choose nursing interventions (e.g., teaching the use of appropriate assistive devices) for that patient. Nurses constantly make clinical decisions to improve a patient's health or maintain wellness. Clinical decision making requires careful reasoning so that you choose the options for the best patient outcomes on the basis of the patient's condition and the priority of the problem or health concern. You improve your clinical decision making by knowing your patients. Nurse researchers found that expert nurses develop a level of knowing that leads to pattern recognition of patient's symptoms and responses (White, 2003). For example, an expert nurse who has worked on a general surgery unit for many years is more likely to detect signs of internal hemorrhage (e.g., fall in blood pressure, rapid pulse, change in consciousness) than is a new nurse. Over time, a combination of knowledge, experience, time spent in a specific clinical area, and the quality of relationships formed with patients allow expert nurses to know clinical situations and quickly anticipate and select the right course of action Chapter 11. Critical Thinking in Nursing Page 17 of 28

18 (Tanner et al., 1993). Spending more time during initial patient assessments to both observe patient behaviour and measure physical findings is a way to improve knowing your patients. Also, consistently monitoring patients as problems occur helps you see how clinical changes develop over time. The selection of nursing actions is built on both clinical knowledge and patient data, including the following: Box 11-2 Research Highlight Working Relationships of Public Health Nurses and High- Priority Families Focus In this study, the nature of working relationships of public health nurses and highrisk (i.e., high-priority) families in northern communities in Canada was examined with the intent of informing nursing practice, education, and policy. Abstract The researchers conducted interviews with 32 families, 25 public health nurses, and 3 lay visitors. An interpretive hermeneutic approach was used to examine the practices and problems nurses and families encountered as care was being provided to a vulnerable, isolated, and often marginalized population, while navigating the complexity and unpredictability of working and living in the same small community. The working relationships of public health nurses and high-risk families were found to be multifaceted and to involve processes related to engaging and entering into relationships, maintaining relationships, and negotiating roles and boundaries. Evidence-Informed Practice The relationships of public health nurses and high-risk families extend beyond the home, clinic, or office and intersect with other facets of everyday life within the community. This means that public health nurses must be attuned to having and using power, maintaining privacy and confidentiality, and setting and crossing boundaries in their work with high-risk families. Working with high-risk families also means that public health nurses must engage them in a manner that opens Chapter 11. Critical Thinking in Nursing Page 18 of 28

19 possibilities for understanding, encourages reflection, builds on the strengths of the families, and invites healing. Reference: Moules, N. J., MacLeod, M. L. P., Thirsk, L. M., & Hanlon, N. (2010). And then you'll see her in the grocery store : The working relationships of public health nurses and high-priority families in northern Canadian communities. Journal of Pediatric Nursing, 25, The identified status and situation of the patient Knowledge about the clinical variables (e.g., patient's age, seriousness of the problem, pathological process of the problem, patient's pre-existing disease conditions) involved in the situation and how the variables are linked together Knowledge about the usual patterns of any diagnosed problem or prognosis and a judgement about the likely course of events and outcomes of the diagnosed problem, in view of any co-existing health risks the patient also possesses Any additional relevant information about the patient's daily living situation, functional capacity, and social resources Knowledge about the nursing interventions available and the way in which specific actions will predictably affect the patient's situation After determining a patient's nursing care priorities, you select actions most likely to relieve each problem or to promote health, wellness, and quality of life. A wide range of choices is often available, from nurse-administered to patient self-care strategies. You collaborate with the patient and then select, test, and evaluate the chosen approaches. Making an accurate clinical decision allows you to set priorities for nursing action. Because each situation involves different patients and different variables, a certain activity is sometimes more of a priority in one situation and less of a priority in another. For example, if a home care patient is physically dependent, unable to eat, and incontinent of urine, skin integrity is of higher priority than if the patient were immobile but continent of urine and able to eat a normal diet. Do not assume that certain health situations produce automatic priorities. For example, an adolescent who has embarked on a smoking cessation program is expected to experience some withdrawal symptoms, which often become a priority of care. However, if the patient is experiencing anxiety about potential weight gain that decreases her ability to participate fully in the program, it becomes necessary for you to focus on ways to relieve the anxiety before the smoking cessation measures will be effective. Chapter 11. Critical Thinking in Nursing Page 19 of 28

20 Nurses make decisions about individual patients and about groups of patients. You use criteria such as the clinical condition of the patients, Maslow's hierarchy of needs, risks involved in treatment delays, and patients' expectations of care to determine which patients have the most urgent priorities for care. For example, a patient in a community care centre who is experiencing a sudden drop in blood pressure along with a change in consciousness requires your attention immediately, as opposed to a small child who requires a routine immunization or a group of expectant parents attending a prenatal class. In order for you to manage the wide variety of problems associated with groups of patients, skillful, prioritized decision making is crucial (Box 11-3). Nursing Process as a Critical Thinking Competency Nurses apply the nursing process as a critical thinking competency when delivering patient care. The nursing process is a five-step clinical decision-making approach that consists of assessment, diagnosis, planning, implementation, and evaluation (see Chapters 12 to 14). The purpose of the nursing process is to assist nurses in identifying and treating patients' health-related concerns and to help patients meet agreed-upon outcomes for better health (Figure 11-2). The nursing process incorporates general (e.g., scientific method, problem solving, and decision making) and specific critical thinking competencies (e.g., diagnostic reasoning, inference, and clinical decision making), described earlier in this chapter, in a manner that focuses on a particular patient's unique needs. The format of the nursing process is unique to the discipline of nursing and provides a common language and process for nurses to think through patients' clinical problems (Kataoka-Yahiro & Saylor, 1994). Chapter 12 describes the nursing process in more detail. Box 11-3 Clinical Decision Making for Groups of Patients Identify the nursing diagnosis and collaborative problems of each patient. Analyze patients' diagnoses or problems and decide which are most urgent in light of the patient's basic needs, changing or unstable status, and problem complexity. Consider the resources available for managing each problem, including unregulated care providers assigned to work with you and the patients' family members. Consider how to involve the patients as decision makers and participants in care. Decide how to combine activities to resolve more than one patient problem at a time. Chapter 11. Critical Thinking in Nursing Page 20 of 28

21 Decide what, if any, nursing care procedures to delegate to unregulated care providers so that you are able to spend your time on activities requiring professional nursing knowledge. The nursing process is often called a blueprint or plan for care. It allows flexibility for use in all clinical settings. When you use the nursing process, you identify a patient's healthrelated concerns, clearly define a nursing diagnosis or collaborative problem, determine priorities of care, and set goals and expected outcomes of care. Then you develop and communicate a plan of care, perform nursing interventions, and evaluate the effects of your care. Involving your patient in each step of the nursing process helps ensure that care is patient centred. When you become more competent in using the nursing process, you are able to focus on multiple problems or diagnoses and to move back and forth between steps when considering all the information available to you about a patient's concerns. Attitudes for Critical Thinking The fourth component of the critical thinking model incorporates the attitudes needed to think critically. An important part of critical thinking is interpreting, evaluating, and making judgements about the adequacy of various arguments and available data. Attitudes determine how a successful critical thinker approaches a problem or a situation that necessitates decision making. For example, when a patient complains of anxiety before undergoing a diagnostic procedure, the curious nurse explores possible reasons for the patient's concerns. The nurse also exhibits discipline and perseverance in taking responsibility to complete a thorough assessment to find the sources of the patient's anxiety. Engaging in inquiry involves an ability to recognize that problems exist and that you need evidence in support of what you suppose to be true (Watson & Glaser, 1980). Figure 11-2 Five-step nursing process model. Chapter 11. Critical Thinking in Nursing Page 21 of 28

22 Knowing when you need more information, knowing when information is misleading, and recognizing your own knowledge limits and personal biases are examples of how critical thinking attitudes play a key role in decision making. Standards for Critical Thinking The fifth component of the critical thinking model includes intellectual and professional standards (Kataoka-Yahiro & Saylor, 1994). Intellectual Standards. An intellectual standard is a guideline or principle for rational thought. You apply such standards when you conduct the nursing process. When you consider a patient problem, apply intellectual standards such as thoroughness, precision, accuracy and consistency to make sure that all clinical decisions are sound. Efficacious use of the intellectual standards in clinical practice ensures that you do not perform critical thinking haphazardly. Professional Standards. Chapter 11. Critical Thinking in Nursing Page 22 of 28

23 Professional standards for critical thinking refer to ethical criteria for nursing judgements, evidence-informed criteria for evaluation, and criteria for professional responsibility. Professional standards promote the highest level of quality nursing care for individuals and groups in institutional and community-based settings. Ethical Criteria for Nursing Judgement. Patient care requires more than just the memorization and application of scientific knowledge (Ironside, 2005). Effective nursing practice reflects sound ethical principles. Being able to focus on a patient's values and beliefs helps you make clinical decisions that are just, faithful to the patient's choices, and beneficial to the patient's health and well-being. The Code of Ethics for Registered Nurses (Canadian Nurses Association, 2008) is based on core values that serve as a guide to ethical decision making in nursing practice. Among these values and ethical responsibilities are providing safe, compassionate, competent, and ethical care; promoting health and well-being; promoting and respecting informed decision making; preserving dignity; maintaining privacy and confidentiality; promoting justice; and being accountable. Critical thinkers maintain a sense of self-awareness through conscious awareness of their own values, beliefs, and feelings and of the multiple perspectives of patients, family members, staff, and peers in clinical situations. Chapter 7 summarizes ethical standards to use when you are faced with ethical dilemmas or problems. One of the patients in a community health clinic is a young man who has signs and symptoms of chlamydia, a sexually transmitted infection. The patient has had the symptoms for more than three weeks and voices concern about what it will mean to have the infection. Richard, a nurse, examines the young man and finds that the patient has redness and itching on his penis, with a yellowish discharge. Richard checks further and asks whether the patient has pain on urination. He also assesses the patient for fever. Richard has limited knowledge about chlamydia, and so he consults with the clinic nurse practitioner, who explains the nature of the infection, the risks it poses to the patient, the usual course of treatment, and some of the legal and ethical guidelines that govern nurses' actions when working with patients with sexually transmitted infections. Richard returns to the patient and speaks confidently with him about chlamydia, the reason for his symptoms, the need to tell sex partners about the infection, and the importance of wearing a condom. Criteria for Evaluation. Nurses routinely use evidence-informed criteria to assess patients' conditions and to determine the efficacy of nursing interventions. For example, accurate assessment of Chapter 11. Critical Thinking in Nursing Page 23 of 28